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Medicare & Other Health Benefits:

Your Guide to

Who Pays First


C E NT E R S

F O R

M E D I C A R E

&

M E D I C A I D

S E RV I C E S

This official government


booklet tells you:
How Medicare works with other
types of coverage
Who should pay your bills first
Where to get more help

Introduction
How this guide can help you
Some people with Medicare have other health coverage that must pay
before Medicare pays its share of the bill. This guide tells how Medicare
works with other kinds of coverage and who should pay your bills first.
Tell your doctor, hospital, and all other health care providers about your
other health coverage to make sure your bills are sent to the right payer
to avoid delays.

Where can I get basic information about Medicare?


Visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users
should call 1-877486-2048.

Table of contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Section 1: When you have other health coverage . . . . . . . . . . . . . . . . . . . . . 5
Who pays first if I have other health coverage? . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Where to go with questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
How Medicare coordinates with other coverage . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Section 2: Medicare & other types of health coverage . . . . . . . . . . . . . . . . . 11


Medicare & Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Medicare & group health plan coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Medicare & group health plan coverage after you retire . . . . . . . . . . . . . . . . . . 13
Medicare & group health plan coverage for people who are disabled
(non-ESRD disability) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Medicare & group health plan coverage for people with EndStage
Renal Disease (ESRD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Medicare & no-fault or liability insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Medicare & workers compensation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Medicare & Veterans benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Medicare & TRICARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Medicare & the Federal Black Lung Benefits Program . . . . . . . . . . . . . . . . . . . 26
Medicare & COBRA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Section 3: Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Section 4: Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Welcome to Medicare & Other Health Benefits:

Your Guide to Who Pays First

The information in this booklet describes the Medicare


program at the time this booklet was printed. Changes
may occur after printing. Visit Medicare.gov, or call
1-800-MEDICARE (18006334227) to get the most current
information. TTY users should call 1-8774862048.
Medicare & Other Health Benefits: Your Guide to Who
Pays First isnt a legal document. Official Medicare
Program legal guidance is contained in the relevant
statutes, regulations, and rulings.

SECTION

When you have other


health coverage
Who pays first if I have other health coverage?
If you have Medicare and other health coverage, each type of coverage is called
a payer. When theres more than one payer, coordination of benefits rules
decide who pays first. The primary payer pays what it owes on your bills first,
and then your provider sends the rest to the secondary payer to pay. In some
cases, there may also be a third payer.
Whether Medicare pays first depends on a number of things, including the
situations listed in the chart on the next 2 pages. However, this chart doesnt
cover every situation. Be sure to tell your doctor and other health care
providers if you have health coverage in addition to Medicare. This will help
them send your bills to the correct payer to avoid delays.
Note: Paying first means paying the bill up to the limits of the payers
coverage. It doesnt always mean the primary payer pays first in time.

Where to go with questions


If you have questions about who pays first, or if your coverage changes,
call the Benefits Coordination & Recovery Center (BCRC) toll-free at
1-855-798-2627. TTY users should call 1-8557972627.
To better serve you, have your Medicare number ready when you call. You can
find your Medicare number on your red, white, and blue Medicare card.
You also may be asked for additional information, like:
Your Social Security Number (SSN)
Words in purple
are defined on
pages 2930.

Address
Medicare effective date(s)
Whether you have Medicare Part A (Hospital Insurance) and/or
Medicare Part B (Medical Insurance) coverage

Section 1: When you have other health coverage

How Medicare coordinates with other coverage


Use the chart below to find your type(s) of coverage and situation to see which payer pays first:
If you

Situation

Pays first

Pays second

Page(s)

Are covered by
Medicare and
Medicaid

Entitled to Medicare and


Medicaid

Medicare

Medicaid, but
only after other
coverage (like
employer group
health plans) has
paid

11

Are 65 or older and


covered by a group
health plan because
you or your spouse is
still working

Entitled to Medicare

Group health plan

Medicare

12

The employer has less than 20


employees*

Medicare

Group health plan

12

Have an employer
group health plan
through your own
former employer after
you retire and are 65
or older

Entitled to Medicare

Medicare

Retiree coverage

1315

Are disabled and


covered by a large
group health plan
from your work,
or from a family
member (like spouse,
domestic partner,
son, daughter or
grandchild) who is
working

Entitled to Medicare

Large group
health plan

Medicare

15

The employer has less than 100


employees

Medicare

Group health plan

15

**Have End-Stage
Renal Disease (ESRD)
(permanent kidney
failure requiring
dialysis or a kidney
transplant) and
group health plan
coverage (including a
retirement plan)

First 30 months of eligibility or


entitlement to Medicare

Group health plan

Medicare

16

After 30 months of eligibility or


entitlement to Medicare

Medicare

Group health plan

16

Have ESRD and


COBRA coverage

First 30 months of eligibility or


entitlement to Medicare on the
basis of ESRD

COBRA

Medicare

27

After 30 months

Medicare

COBRA

16

The employer has 20 or more


employees

The employer has 100 or more


employees

* If your employer participates in a plan thats sponsored by 2 or more employers, the rules are slightly different.
** If you originally got Medicare due to your age or a disability other than ESRD, and Medicare was your primary payer, it still pays first
when you become eligible due to ESRD.

Section 1: When you have other health coverage

If you

Situation

Pays first

Pays second

Page(s)

Are 65 or over OR
disabled and covered
by Medicare and
COBRA coverage

Entitled to Medicare

Medicare

COBRA

2627

Have been in an
accident where
no-fault or liability
insurance is involved

Entitled to Medicare

No-fault or liability
insurance for services
related to accident claim

Medicare

1719

Are covered
under workers
compensation
because of a
jobrelated illness or
injury

Entitled to Medicare

Workers compensation
for services related to
workers compensation
claim

Usually doesnt
apply. However,
Medicare may
make a conditional
payment (a payment
that must be repaid
to Medicare when
a settlement,
judgment, award,
or other payment is
made.)

1923

Are a Veteran and


have Veterans
benefits

Entitled to Medicare
and Veterans benefits

Medicare pays for


Medicare- covered
services.

Usually doesnt apply

2324

TRICARE may pay


second.

2425

Medicare

26

Veterans Affairs pays for


VA-authorized services.
Note: Generally,
Medicare and VA cant
pay for the same service.
Are covered under
TRICARE

Entitled to Medicare
and TRICARE

Medicare pays for


Medicare- covered
services.
TRICARE pays for
services from a military
hospital or any other
federal provider.

Have black lung


disease and are
covered under the
Federal Black Lung
Benefits Program

Entitled to Medicare
and the Federal Black
Lung Benefits Program

The Federal Black Lung


Benefits Program for
services related to black
lung.

Section 1: When you have other health coverage

How Medicare coordinates with other coverage


Im not yet 65. How will Medicare know I have other coverage?
About 3 months before you get Medicare, Medicare will send you a letter with
a username and password for MyMedicare.gov. This is a free, secure online
service where you can keep personalized information on your Medicare benefits
and services. Medicare doesnt automatically know if you have other coverage.
Fill out your Initial Enrollment Questionnaire (IEQ) at MyMedicare.gov to
make sure your medical bills are paid correctly and on time.
The IEQ asks if you have group health plan coverage through your work or a
family members work. Medicare uses your answers to help set up your file and
make sure your claims get paid correctly.
You can also complete your IEQ over the phone by calling the Benefits
Coordination & Recovery Center (BCRC) toll-free at 1-855-798-2627.
TTYusers should call 1-855-797-2627.
Example: Harry is almost 65 and is getting ready to retire and enroll in
Medicare. Harrys wife Jane, 63, works for a large company (more than 20
people). Both Harry and Jane have health coverage through Janes employers
group health plan.
After he gets a letter from Medicare with his username and password for
MyMedicare.gov, Harry goes to the website and fills out his IEQ. He reports he
has coverage through his wifes employment. This insurance will pay Harrys
claims first, and Medicare will pay Harrys claims second.
What happens if my health coverage changes after I fill out the IEQ?
Call the BCRC and give this information:
Your name
The name and address of your health plan
Your policy number
The date coverage was added, changed, or stopped, and why
Tell your doctor and other health care providers about changes in your coverage
when you get care.

Section 1: When you have other health coverage

How Medicare coordinates with other coverage (continued)


What if I have Medicare and more than one type of coverage?
Check your insurance policyit may include the rules about who pays first.
You can also call the Benefits Coordination & Recovery Center (BCRC) toll-free
at 1-855-798-2627. TTY users should call 1-855-797-2627.
Where can I get more information about who pays first?
Call your health insurance plans benefits administrator. You can also call the
BCRC.

10

Section 1: When you have other health coverage

Notes

11

SECTION

Medicare & other types


of health coverage
Medicare & Medicaid
Medicaid (also called Medical Assistance) is a joint federal and state
program that helps pay medical costs for certain people and families
who have limited income and resources and meet other requirements.
Medicaid never pays first for services covered by Medicare. It only
pays after Medicare, employer group health plans, and/or Medicare
Supplement Insurance (Medigap) policies have paid.

Medicare & group health plan coverage


You have a number of important decisions to make when you turn 65,
like whether you should enroll in Medicare Part B (Medical Insurance),
join a Medicare Prescription Drug Plan, buy a Medigap policy, and/or
keep employer or retiree coverage. Byunderstanding your choices, you
can avoid paying more than you need to, and get coverage that meets your
needs.
Visit Medicare.gov/find-a-plan to compare Medicare health and drug
plans in your area. You can also call your State Health Insurance
Assistance Program (SHIP). Visit Medicare.gov/contacts, or call
1-800-MEDICARE (1-800-633-4227) to get the SHIP phone number.
TTYusers should call 1-8774862048.
Should I get group health plan coverage?

Words in purple
are defined on
pages 2930.

Many employers and unions offer group health plan coverage to current
employees or retirees. You may also get group health plan coverage
through the employer of a spouse or family member.
If you have Medicare and youre offered coverage under a group health
plan, you can choose to accept or reject the plan. The group health plan
may be a fee-for-service plan or a managed care plan, like an HMO or
PPO.

12

Section 2: Medicare & other types of health coverage

Medicare & group health plan coverage (continued)


I have Medicare and group health plan coverage. Who pays first?
Generally, your group health plan pays first if both of these are true:
1. Youre 65 or older and covered by a group health plan through your current
employer or the current employer of a spouse of any age.
2. The employer has 20 or more employees and covers any of the same services
as Medicare (this means the group health plan pays first on your hospital and
medical bills.)
If the group health plan didnt pay all of your bill, the doctor or health care
provider should bill Medicare for secondary payment. Medicare will look
at what your group health plan paid, and pay any additional costs up to the
Medicare-approved amounts as appropriate. Youll have to pay whatever costs
Medicare or the group health plan doesnt cover.
If your employer has less than 20 employees, Medicare generally pays first. But
if your employer joins with other employers or employee organizations (like
unions) to sponsor a group health plan (called a multi-employer plan), and any
of the other employers has 20 or more employees, Medicare would generally
pay second. However, your plan might ask for an exception, so even if your
employer has less than 20 employees, youll need to find out from your
employer whether Medicare pays first or second.
Im in a Health Maintenance Organization (HMO) Plan or an employer
Preferred Provider Organization (PPO) Plan that pays first. Who pays if I go
outside the employer plans network?
If you go for care outside your employer plans network, you might not get any
payment from your plan or Medicare. Call your plan before you go outside the
network to find out if the service will be covered.
I decided not to take group health plan coverage from my employer. Will
this affect what Medicare will pay?
Medicare pays its share for any Medicare-covered health care service you get if
you dont take group health plan coverage from your employer, and you dont
have coverage through an employed spouse.

Section 2: Medicare & other types of health coverage

13

Medicare & group health plan coverage (continued)


What happens if I drop coverage from my employer?
Medicare pays first unless you have coverage through an employed spouse, and your
spouses employer has at least 20 employees.
Note: If you dont take employer coverage when its first offered to you, you might
not get another chance to sign up. If you take the coverage but drop it later, you
may not be able to get it back. Also, you might be denied coverage if your employer
or your spouses employer generally offers retiree coverage but you werent in the
plan while you or your spouse was still working. Call your employers benefits
administrator for more information before you make a decision.
If Im 65 or older and still working, what health benefits does my employer
have to offer me?
Generally, employers with 20 or more employees must offer current employees
65 and older the same health benefits, under the same conditions, that they offer
younger employees. If the employer offers coverage to spouses, it must offer the
same coverage to spouses 65 and older that it offers to spouses under 65.

Medicare & group health plan coverage after you retire


How does my group health plan coverage work after I retire?
It depends on the terms of your specific plan. Your employer or union or your
spouses employer or union might not offer any health coverage after you retire.
Ifyou can get group health plan coverage after you retire, it might have different
rules and might not work the same way with Medicare.
Can I continue my employer coverage after I retire?
Generally, when you have retiree coverage from an employer or union, they manage
this coverage. Employers arent required to provide retiree coverage, and they can
change benefits or premiums, or even cancel coverage.
What are the price and benefits of the retiree coverage, and does it include
coverage for my spouse?
Your employer or union may offer retiree coverage that limits how much it will pay.
It might only provide stop loss coverage, which starts paying your out-of-pocket
costs only when they reach a maximum amount.

14

Section 2: Medicare & other types of health coverage

Medicare & group health plan coverage after you retire


(continued)
What happens to my retiree coverage when Im eligible for Medicare?
If your former employer offers retiree coverage, the coverage might not pay your
medical costs during any period in which you were eligible for Medicare but didnt
sign up for it. When you become eligible for Medicare, you may need to join
both Medicare Part A and Medicare Part B to get full benefits from your retiree
coverage.
What effect will my continued coverage as a retiree have on both my health
coverage and my spouses health coverage?
If youre not sure how your retiree coverage works with Medicare, get a copy of
your plans benefit materials, or look at the summary plan description provided by
your employer or union. Youcan also call your employers benefits administrator
and ask how the plan pays when you have Medicare. You may want to talk to your
State Health Insurance Assistance Program (SHIP) for advice about whether to
buy a Medicare Supplement Insurance (Medigap) policy.
How does retiree coverage compare with a Medicare Supplement Insurance
(Medigap) policy?
Since Medicare pays first after you retire, your retiree coverage is likely to be
similar to coverage under a Medigap policy. Retiree coverage isnt the same thing
as a Medigap policy but, like a Medigap policy, it usually offers benefits that fill
in some of Medicares gaps in coverage, such as coinsurance and deductibles.
Sometimes retiree coverage includes extra benefits, like coverage for extra days in
the hospital.
If I choose to buy a Medigap policy, when should I buy it?
The best time is during your 6-month Medigap Open Enrollment period, because
you can buy any Medigap policy sold in your state, even if you have health
problems. This period automatically starts the month youre 65 and enrolled in
Part B, and once its over, you cant get it again.
Remember: You and your spouse would each have to buy your own Medigap
policy, and you can only buy a policy when youre eligible for Medicare.
For more information about Medigap policies, visit Medicare.gov/publications to
view the booklet Choosing a Medigap Policy: A Guide to Health Insurance for
People with Medicare. To find and compare Medigap polices, visit
Medicare.gov/find-a-plan, or call 1-800-MEDICARE (1-800-633-4227). TTYusers
should call 1-877-486-2048.

Section 2: Medicare & other types of health coverage

15

Medicare & group health plan coverage after you retire


(continued)
Im retired and have Medicare. I also have group health plan coverage from
my own former employer. Who pays first?
Generally, Medicare pays first for your health care bills and your group health
plan (retiree) coverage pays second.
Im retired and have Medicare. My spouse is still working and I have group
health plan coverage through my spouses employer. Who pays first?
If your spouses employer has 20 or more employees, your spouses coverage
pays first and Medicare pays second. If your spouses employer has less than 20
employees, Medicare pays first.
What happens if I have group health plan coverage after I retire and my
former employer goes bankrupt or out of business?
If your former employer goes bankrupt or out of business, federal COBRA rules
may protect you if any other company within the same corporate organization
still offers a group health plan to its employees. That plan is required to offer
you COBRA continuation coverage. See pages 2627. If you cant get COBRA
continuation coverage, you may have the right to buy a Medigap policy even if
youre no longer in your Medigap Open Enrollment Period.

Medicare & group health plan coverage for people who are
disabled (non-ESRD disability)
Im under 65, disabled, and have Medicare and group health plan coverage
based on current employment. Who pays first?
It depends. Generally, if your employer has less than 100 employees, Medicare
pays first if youre under 65 or if you have Medicare because of a disability.
Sometimes employers with less than 100 employees join with other employers to
form a multi-employer plan. If at least one employer in the multi-employer plan
has 100 employees or more, Medicare pays second.

16

Section 2: Medicare & other types of health coverage

Medicare & group health plan coverage for people who are
disabled (non-ESRD disability) (continued)
Im under age 65, disabled, and have Medicare and group health plan
coverage based on current employment. Who pays first? (continued)
If the employer has at least 100 employees, the health plan is called a large group
health plan. If youre covered by a large group health plan because of your current
employment or the current employment of a family member (including, but not
limited to a spouse, a domestic partner, son, daughter, or grandchild), Medicare
pays second. A large group health plan cant treat any plan member differently
because theyre disabled and have Medicare.
Example: Mary works full-time for a company that has 120 employees. She has large
group health plan coverage for herself and her husband. Her husband has Medicare
because of a disability, so Marys group health plan coverage pays first for Marys
husband, and Medicare pays second.

Medicare & group health plan coverage for people with


EndStage Renal Disease (ESRD)
I have ESRD and group health plan coverage. Who pays first?
If youre eligible for Medicare because of ESRD, your group health plan will pay first
on your hospital and medical bills for 30 months, whether or not youre in Medicare.
During this time, Medicare pays second.
The group health plan pays first during this period no matter how many employees
work for your employer, or whether you or a family member are currently
employed. At the end of the 30 months, Medicare pays first. This rule applies to
most people with ESRD, whether you have your own group health plan coverage, or
youre covered as a family member.
Example: Bill has Medicare coverage because of ESRD. He also has group health
plan coverage through his company. Bills group health plan coverage will pay first
for the first 30 months after he becomes eligible for Medicare. After 30 months,
Medicare pays first.

Section 2: Medicare & other types of health coverage

17

Medicare & no-fault or liability insurance


Whats no-fault insurance?
No-fault insurance may pay for health care services you get because you get injured
or your property gets damaged in an accident, regardless of who is at fault for
causing the accident.
Some types of no-fault insurance include:
Automobile insurance
Homeowners insurance
Commercial insurance plans
Whats liability insurance?
Liability insurance protects against claims for negligencefor example,
inappropriate action or inaction that causes someone to get injured or causes
property damage.
Some types of liability insurance include:
Homeowners
Automobile
Product
Malpractice
Uninsured motorist
Underinsured motorist
If you have an insurance claim for your medical expenses, you or your lawyer
should notify Medicare as soon as possible.
Who pays first if I have a claim for no-fault or liability insurance?
No-fault insurance or liability insurance pays first and Medicare pays second, if
appropriate.
If doctors or other providers are told you have a no-fault or liability insurance claim,
they must try to get paid from the insurance company before billing Medicare.
However, this may take a long time. If the insurance company doesnt pay the
claim promptly (usually within 120 days), your doctor or other provider may bill
Medicare. Medicare may make a conditional payment to pay the bill, and then later
get back any payments the primary payer should have made.

18

Section 2: Medicare & other types of health coverage

Medicare & no-fault or liability insurance (continued)


Who pays first if I have a claim for no-fault or liability insurance? (continued)
Example: Nancy is 69 years old. Shes a passenger in her granddaughters car, and
they have an accident. Nancys granddaughter has Personal Injury Protection/
Medical Payments (Med Pay) coverage as part of her automobile insurance. While
at the hospital emergency room, Nancy is asked about available coverage related to
the accident. Nancy tells the hospital that her granddaughter has Med Pay coverage.
Because this coverage pays regardless of fault, its considered no-fault insurance. The
hospital bills the no-fault insurance for the emergency room services, and only bills
Medicare if any Medicare-covered services arent paid for by the no-fault insurance.
Whats a conditional payment?
A conditional payment is a payment Medicare makes for services another payer may
be responsible for. Medicare makes this conditional payment so you wont have to
use your own money to pay the bill. The payment is conditional because it must be
repaid to Medicare when a settlement, judgment, award, or other payment is made.
Note: If Medicare makes a conditional payment for an item or service, and you
get a settlement, judgment, award, or other payment for that item or service from
an insurance company later, the conditional payment must be repaid to Medicare.
Youre responsible for making sure Medicare gets repaid for the conditional
payment.
Example: Joan is driving her car when someone in another car hits her. Joan has
to go to the hospital. The hospital tries to bill the other drivers liability insurer.
The insurance company disputes who was at fault and wont pay the claim right
away. The hospital bills Medicare, and Medicare makes a conditional payment to
the hospital for health care services Joan got. When a settlement is reached with
the liability insurer, Joan must make sure Medicare gets its money back for the
conditional payment.

Section 2: Medicare & other types of health coverage

19

Medicare & no-fault or liability insurance (continued)


How does Medicare get its money back for the conditional payment?
If Medicare makes a conditional payment, you or your representative should call
the Benefits Coordination & Recovery Center (BCRC) toll-free at 1-855-798-2627.
TTYusers should call 1-855-797-2627. The BCRC will work on your case, using the
information you or your representative gives it to see that Medicare gets repaid for
the conditional payments.
The BCRC will gather information about any conditional payments Medicare made
related to your pending settlement, judgment, award, or other payment. Once a
settlement, judgment, award, or other payment is final, you or your representative
should call the BCRC. The BCRC will get the final repayment amount (if any) on
your case and issue a letter requesting repayment.
Who pays if the no-fault or liability insurance denies my medical bill or is
found not liable for payment?
Medicare would pay for covered services, unless you have group health plan
coverage that must pay before Medicare. Youre responsible for your share of the
bill, like coinsurance, copayment, or a deductible, and for services Medicare doesnt
cover.
Where can I get more information?
If you have questions about a no-fault or liability insurance claim, call the insurance
company. If you have questions about who pays first, call the BCRC.

Medicare & workers compensation


Whats workers compensation?
Workers compensation is a law or plan requiring employers to cover employees
who get sick or injured on the job. Workers compensation plans cover most
employees. If you dont know whether youre covered, ask your employer, or contact
your state workers compensation division or department.

20

Section 2: Medicare & other types of health coverage

Medicare & workers compensation (continued)


I have Medicare and filed a workers compensation claim. Who pays first?
If you have Medicare and get injured on the job, workers compensation pays first on
health care items or services you got because of your work-related illness or injury.
There can be a delay between when a bill is filed for the work-related illness or
injury and when the state workers compensation insurance decides if they should
pay the bill. Medicare cant pay for items or services that workers compensation will
pay for promptly (generally 120 days).
However, if the workers compensation insurer denies payment for your medical
bills pending a review of your claim (generally 120 days or longer), Medicare may
make a conditional payment. This isnt the same situation as when your workers
compensation case has been settled and youre using funds from your Workers
Compensation Medicare Set-aside Arrangement (WCMSA) to pay for your medical
care. See next page for more information on WCMSAs.
If you think you have a work-related illness or injury, tell your employer, and
file a workers compensation claim.
You or your lawyer also need to call the BCRC toll-free at 1-855-798-2627 as soon as
you file your workers compensation claim. TTY users should call 1-855-797-2627.
Example: Tom was injured at work. He filed a claim with workers compensation
insurance. His doctor billed the state workers compensation insurance for payment.
Toms doctor didnt get paid within 120 days, so he billed Medicare and sent a
copy of Toms workers compensation claim with the claim for Medicare payment.
Medicare made a conditional payment to the doctor for the health care services Tom
got. When a settlement is reached with the state workers compensation agency,
Tom must make sure Medicare gets its money back for the conditional payment.

Section 2: Medicare & other types of health coverage

21

Medicare & workers compensation (continued)


How does Medicare get its money back for the conditional payment?
If Medicare makes a conditional payment, and you or your lawyer havent reported
your workers compensation claim to Medicare, call the Benefits Coordination
& Recovery Center (BCRC) toll-free at 1-855-798-2627. TTY users should call
1-855797-2627. The BCRC will work on your case, using the information you
or your representative gives it to see that Medicare gets repaid for the conditional
payments.
The BCRC will gather information about any conditional payments Medicare made
relating to your pending settlement, judgment, award or other payment. Once a
settlement, judgment, award or other payment is final, you or your lawyer should
call the BCRC. The BCRC will get the final repayment amount (if any) on your case
and issue a letter requesting repayment.
What if I want to settle my workers compensation claim?
You or your lawyer should contact the BCRC. Settlements of workers compensation
claims are handled differently than a settlement of a no-fault or liability insurance
claim. As part of settling your workers compensation claim, you must repay
Medicare for any Medicare payments for workers compensation claimrelated
services you already got.
When and why would I need a Workers Compensation Medicare Set-aside
Arrangement (WCMSA)?
If you settle your workers compensation claim, the settlement may provide for funds
to be set aside to pay for future medical and prescription drug expenses related to your
injury, illness or disease. When you have Medicare, you may wish to ask your workers
compensation lawyer about the possibility of setting up a Workers Compensation
Medicare Set-aside Arrangement (WCMSA) for depositing these funds.
The WCMSA ensures workers compensation funds are spent on these future
expenses otherwise covered by Medicare. In other words, workers compensation
pays before Medicare for these future expenses. If you have a WCMSA as part of
your workers compensation settlement, you must be careful how you spend money
specifically set aside for Medicare.
You or your lawyer need to send your proposed WCMSA to the BCRC at:
WCMSA Proposal/Final Settlement
P.O. Box 138899
Oklahoma City, OK 73113-8899

22

Section 2: Medicare & other types of health coverage

Medicare & workers compensation (continued)


How am I allowed to use the money in my Workers Compensation Medicare
Set-aside Arrangement (WCMSA) if I manage (self-administer) the account?
Keep these in mind if you manage your WCMSA account:
Money placed in your WCMSA is for paying future medical expenses, including
prescription drug expenses related to your work injury or illness/disease that
otherwise would have been paid back by Medicare. You should also use WCMSA
funds to pay for these medical services and items, as well as prescription drug
expenses, if youre enrolled in a Medicare Advantage Plan.
You cant use the WCMSA to pay for any other work injury, or any medical items
or services that Medicare doesnt cover (like dental services).
Medicare wont pay for any medical expenses related to the injury until after you
have used all of your set-aside money appropriately.
If you arent sure what type of services Medicare covers, visit Medicare.gov or call
1-800-MEDICARE (1-800-633-4227) for more information, before you use any
of the money that was placed in your WCMSA account. TTY users should call
1-8774862048.
Keep records of your workers compensation-related medical expenses, including
prescription drug expenses. These records show what items and services you got
and how much money you spent on your work-related injury, illness, or disease.
You need these records to prove you used your WCMSA money to pay your
workers compensation-related medical expenses, including prescription drug
expenses.
After you use all of your WCMSA money appropriately, Medicare can start paying
for Medicare-covered services related to your work-related injury, illness, or
disease.
What if workers compensation denies payment?
If workers compensation insurance denies payment, and you give Medicare proof
that the claim was denied, Medicare will pay for Medicare-covered items and
services as appropriate.
Example: Mike was injured at work. He filed a workers compensation claim.
Theworkers compensation agency denied payment for Mikes medical bills. Mikes
doctor billed Medicare and sent Medicare a copy of the workers compensation
denial with the claim for Medicare payment. Medicare will pay Mikes doctor for the
Medicare-covered items and services Mike got as part of his treatment. Mike must
pay for anything Medicare doesnt cover.

Section 2: Medicare & other types of health coverage

23

Medicare & workers compensation (continued)


Can workers compensation decide not to pay my entire bill?
In some cases, workers compensation insurance may not pay your entire bill.
Ifyou had an injury or illness before you started your job (called a pre-existing
condition), and the job made it worse, workers compensation may not pay your
whole bill because the job didnt cause the original problem. In this case, workers
compensation insurance may agree to pay only a part of your doctor or hospital
bills. You and workers compensation insurance may agree to share the cost of your
bill. If Medicare covers the treatment for your pre-existing condition, then Medicare
may pay its share for part of the doctor or hospital bills that workers compensation
doesnt cover.

Medicare & Veterans benefits


I have Medicare and Veterans benefits. Who pays first?
If you have or can get both Medicare and Veterans benefits, you can get treatment
under either program. When you get health care, you must choose which benefits
to use each time you see a doctor or get health care. Medicare cant pay for the same
service that was covered by Veterans benefits, and your Veterans benefits cant
pay for the same service that was covered by Medicare. Also, Medicare is never the
secondary payer after the Department of Veterans Affairs (VA). Note: to get the VA
to pay for services, you must go to a VA facility or have the VA authorize services in
a non-VA facility.
Are there any situations when both Medicare and the VA may pay?
Yes. If the VA authorizes services in a non-VA hospital, but didnt authorize all of the
services you get during your hospital stay, then Medicare may pay for the Medicarecovered services the VA didnt authorize.
Example: Bob, a Veteran, goes to a non-VA hospital for a service authorized by
the VA. While at the non-VA hospital, Bob gets other non-VA authorized services
that the VA wont pay for. Some of these services are Medicare-covered services.
Medicare may pay for some of the non-VA authorized services that Bob got. Bob
will have to pay for services that Medicare or the VA doesnt cover.

24

Section 2: Medicare & other types of health coverage

Medicare & Veterans benefits (continued)


I have a VA fee-basis identification (ID) card. Who pays first?
The VA may give fee-basis ID cards to certain Veterans if these conditions apply:
You have a service-connected disability.
Youll need medical services for an extended time period.
There are no VA hospitals in your area.
If you have a fee-basis ID card, you may choose any doctor listed on your card to
treat you.
If the doctor accepts you as a patient and bills the VA for services, the doctor must
accept the VAs payment as payment in full. The doctor cant bill you or Medicare for
these services.
If your doctor doesnt accept the fee-basis ID card, youll need to file a claim with
the VA yourself. The VA will pay the approved amount either to you or to your
doctor.
Where can I get more information on Veterans benefits?
Visit VA.gov, call your local VA office, or call the national VA information number
at 1-800-827-1000. TTY users should call 1-800-829-4833.

Medicare & TRICARE


Whats TRICARE?
TRICARE is a health care program for active-duty and retired uniformed services
members and their families that includes:
TRICARE Prime.
TRICARE Extra.
TRICARE Standard.
TRICARE for Life (TFL). TFL provides expanded medical coverage to
Medicare-eligible uniformed services retirees 65 or older, to their eligible family
members and survivors, and to certain former spouses. You must have Medicare
Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) to get TFL
benefits.

Section 2: Medicare & other types of health coverage

25

Medicare & Veterans benefits (continued)


Can I have both Medicare and TRICARE?
Some people can have both Medicare and other types of TRICARE, including:
Dependents of active-duty service members who are allowed Medicare for any
reason.
People under 65 with Medicare Part A (Hospital Insurance) because of a
disability or End-Stage Renal Disease (ESRD) and with Medicare Part B (Medical
Insurance).
People 65 or older who can get Part A and who join Part B.
I have Medicare and TRICARE. Who pays first?
In general, Medicare pays first for Medicare-covered services. TRICARE will pay
the Medicare deductible and coinsurance amounts and for any service not covered
by Medicare that TRICARE covers. You pay the costs of services Medicare or
TRICARE doesnt cover.
Who pays if I get services from a military hospital?
If you get services from a military hospital or any other federal health care provider,
TRICARE will pay the bills. Medicare usually doesnt pay for services you get from a
federal health care provider or other federal agency.
Where can I get more information?
Visit Tricare.mil/tfl.
Call the health benefits advisor at a military hospital or clinic.
Call 1-866-773-0404.

26

Section 2: Medicare & other types of health coverage

Medicare & the Federal Black Lung Benefits Program


I have Medicare and coverage under the Federal Black Lung Benefits Program.
Who pays first?
The Federal Black Lung Benefits Program pays first for any health care for black
lung disease covered under that program. Medicare wont pay for doctor or hospital
services covered under the Federal Black Lung Benefits Program. Your doctor or
other health care provider should send all bills for the diagnosis or treatment of
black lung disease to:
Federal Black Lung Program
P.O. Box 8302
London, Kentucky 40742-8302
For all other health care not related to black lung disease, Medicare pays first, and
your doctor or health care provider should send your bills directly to Medicare.
What if the Federal Black Lung Benefits Program wont pay my bill?
Ask your doctor or other health care provider to send Medicare the bill. Ask them to
include a copy of the letter from the Federal Black Lung Benefits Program that says
why it wont pay your bill.
Where can I get more information?
Call 1-800-638-7072 if you have questions about the Federal Black Lung Benefits
Program. If you have questions about who pays first, call the Benefits Coordination
& Recovery Center (BCRC) toll-free at 1-855-798-2627. TTY users should call
1-855-797-2627.

Medicare & COBRA


Whats COBRA?
COBRA is a federal law that may allow you to temporarily keep employer or union
health coverage after the employment ends or after you lose coverage as a dependent
of the covered employee. This is called continuation coverage.
In general, COBRA only applies to employers with 20 or more employees. However,
some state laws require insurers covering employers with fewer than 20 employees
to let you keep your coverage for a period of time.
In most situations that give you COBRA rights (other than a divorce), you should
get a notice from your employers benefits administrator or the group health plan
telling you your coverage is ending and offering you the right to elect COBRA
continuation coverage.

Section 2: Medicare & other types of health coverage

27

Medicare & COBRA (continued)


This coverage generally is offered for 18 months (or 36 months, in some cases).
If you dont get a notice, but you find out your coverage has ended, or if you get
divorced, call the employers benefits administrator or the group health plan as soon
as possible and ask about your COBRA rights.
If you qualify for COBRA because the covered employee either died, lost his/her job,
or can now get Medicare, then the employer must tell the plan administrator. Once
the plan administer is notified, the plan must let you know you have the right to
choose COBRA coverage.
However, if you qualify for COBRA because youve become divorced or legally
separated (court issued separation decree) from the covered employee, or if you
were a dependent child or dependent adult child who is no longer a dependent, then
you or the covered employee needs to let the plan administrator know about your
change in situation within 60 days of the change happening.
I have Medicare and COBRA continuation coverage. Who pays first?
In general, the rules described on pages 1215 that apply to group health plan
coverage also apply to COBRA continuation coverage. For example, if you or your
spouse are 65 or over, retired, and have COBRA continuation coverage, Medicare
pays first.
If you have Medicare based on End-Stage Renal Disease (ESRD), COBRA
continuation coverage pays first. Medicare pays second to the extent COBRA coverage
overlaps the first 30 months of Medicare eligibility or entitlement based on ESRD.
Whether and when you should elect COBRA coverage can be a very complicated
decision. When you lose employer coverage and you have Medicare, you need to
be aware of your COBRA election period, your Part B enrollment period, and your
Medigap Open Enrollment Period. These may all have different deadlines that
overlap, so be aware that what you decide about one type of coverage (COBRA,
Part B, and Medigap) might cause you to lose rights under one of the other types of
coverage.

28

Section 2: Medicare & other types of health coverage

Medicare & COBRA (continued)


Where can I get more information about COBRA?
Before you elect COBRA coverage, you can talk with your State Health Insurance
Assistance Program (SHIP) about Medicare Part B (Medical Insurance) and
Medicare Supplementary (Medigap) Insurance. Visit Medicare.gov/contacts, or
call 1-800-MEDICARE (1-800-633-4227) to get the phone number. TTY users
should call 1-877-486-2048.
Call your employers benefits administrator for questions about your specific
COBRA options.
If you have questions about Medicare and COBRA, call the Benefits Coordination
& Recovery Center (BCRC) toll-free at 1-855-798-2627. TTY users should call
1-8557972627.
If your group health plan coverage was from a private employer (not a
government employer), visit the Department of Labor at dol.gov, or call
1-866444-3272.
If your group health plan coverage was from a state or local government employer,
call the Centers for Medicare & Medicaid Services (CMS) at 1-877-267-2323,
extension 61565.
If your coverage was with the federal government, visit the Office of Personnel
Management at opm.gov.

29

SECTION

Definitions

Where words in purple are defined


Benefits Coordination & Recovery Center (BCRC)The
company that acts on behalf of Medicare to collect and manage
information on other types of insurance or coverage that a
person with Medicare may have, and determine whether the
coverage pays before or after Medicare. This company also acts
on behalf of Medicare to obtain repayment when Medicare
makes a conditional payment, and the other payer is determined
to be primary.
ClaimA request for payment that you submit to Medicare or
other health insurance when you receive items and services that
you think are covered.
CoinsuranceAn amount you may be required to pay as your
share of the cost for services, after you pay any deductibles.
Coinsurance is usually a percentage (for example, 20%).
CopaymentAn amount you may be required to pay as
your share of the cost for a medical service or supply, like a
doctors visit, hospital outpatient visit, or a prescription drug.
A copayment is usually a set amount, rather than a percentage.
For example, you might pay $10 or $20 for a doctors visit or
prescription.
DeductibleThe amount you must pay for health care or
prescriptions, before Original Medicare, your prescription drug
plan, or your other insurance begins to pay.
End-Stage Renal Disease (ESRD)Permanent kidney failure
that requires a regular course of dialysis or a kidney transplant.
Group health planIn general, a health plan offered by an
employer or employee organization that provides health coverage
to employees, former employees, and their families.

30

Section 3: Definitions

Health care providerA person or organization


thats licensed to give health care. Doctors,
nurses, and hospitals are examples of health care
providers.
Large group health planIn general, a group
health plan that covers employees of either an
employer or employee organization that has at least
100 employees.
MedicaidA joint federal and state program that
helps with medical costs for some people with
limited income and resources. Medicaid programs
vary from state to state, but most health care costs
are covered if you qualify for both Medicare and
Medicaid.
Medicare Part A (Hospital Insurance)
Coverage for inpatient hospital stays, care in a
skilled nursing facility, hospice care, and some
home health care.

Medicare prescription drug plan


(Part D)Astand-alone drug plan that adds
prescription drug coverage to Original Medicare,
some Medicare Cost Plans, some Medicare
Private-Fee-for-Service Plans, and Medicare
Medical Savings Account Plans. These plans are
offered by insurance companies and other private
companies approved by Medicare. Medicare
Advantage Plans may also offer prescription drug
coverage that follows the same rules as Medicare
Prescription Drug Plans.

Medigap policyMedicare Supplement Insurance


sold by private insurance companies to fill gaps in
Original Medicare coverage.

Multi-employer planIn general, a group

health plan thats sponsored jointly by 2 or more


employers.

PremiumThe periodic payment to Medicare, an


Medicare Part B (Medical Insurance)Coverage insurance company, or a health care plan for health
for certain doctors services, outpatient care,
or prescription drug coverage.
medical supplies, and preventive services.
Medicare Advantage Plan (Part C)A type
of Medicare health plan offered by a private
company that contracts with Medicare to provide
you with all your Medicare Part A and Part B
benefits. Medicare Advantage Plans include Health
Maintenance Organizations, Preferred Provider
Organizations, Private Fee-for-Service Plans,
Special Needs Plans, and Medicare Medical Savings
Account Plans. If youre enrolled in a Medicare
Advantage Plan, Medicare services are covered
through the plan and arent paid for under Original
Medicare. Most Medicare Advantage Plans offer
prescription drug coverage.

State Health Insurance Assistance Program


(SHIP)A state program that gets money from

the federal government to give free local health


insurance counseling to people with Medicare.

TTYA TTY (teletypewriter) is a communication

device used by people who are deaf, hard-ofhearing, or have a severe speech impairment. People
who dont have a TTY can communicate with a
TTY user through a message relay center (MRC).
An MRC has TTY operators available to send and
interpret TTY messages.

Workers compensationA plan that employers

are required to have to cover employees who get


sick or injured on the job.

31

SECTION

Index

An alphabetical list of whats in this guide


1-800-MEDICARE 11, 14, 22, 24, 26
A
Accident 7, 17
B
Benefits Coordination & Recovery Center
(BCRC) 5, 8, 9, 1921, 2628, 29
Black lung disease 7, 26
C
Claim 7, 8, 1722, 24, 29
COBRA 6, 7, 15, 2628
Coinsurance 14, 19, 25, 29
Conditional payment 7, 1721
Copayment 19, 29
D
Deductible 14, 19, 25, 29
Denial of payment 22
Disabled 6, 7, 1516
E
End-Stage Renal Disease 6, 16, 25, 27, 29
F
Federal Black Lung Program 7, 26
G
Group health plan 6, 8, 1116, 19, 2628, 29

32

Section 4: Index

H
Health care provider 2, 5, 7, 8, 12, 17, 25, 26, 30
I
Initial Enrollment Questionnaire 8
L
Large group health plan 6, 1516
Liability Insurance 7, 1719
M
Medicaid 6, 11, 30
Medicare Part A (Hospital Insurance) 5, 14, 24, 25, 30
Medicare Part B (Medical Insurance) 5, 11, 14, 24, 25, 27, 28, 30
Medicare prescription drug coverage (Part D) 11, 21, 22, 30
Medicare secondary payer 5, 12, 23
Medigap 11, 14, 15, 27, 28, 30
Multi-employer plan 12, 15, 30
N
No-fault insurance 7, 1719
P
Pre-existing condition 23
Premium 13, 30
Primary payer 5, 17
R
Retiree coverage 6, 11, 1315
S
State Health Insurance Assistance Program (SHIP) 11, 14, 28, 30
T
TRICARE 7, 2425
TRICARE for Life (TFL) 24
V
Veterans benefits 7, 2325
W
Workers compensation 7, 1923
Workers Compensation Medicare Set-aside Arrangement
(WCMSA) 2022

U.S. DEPARTMENT OF
HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
7500 Security Boulevard
Baltimore, Maryland 21244-1850
Official Business
Penalty for Private Use, $300
CMS Product No. 02179
Revised April 2014

Medicare.gov
1-800-MEDICARE (1-800-633-4227)
TTY: 1-877-486-2048
Necesita usted una copia en espaol?
Llame GRATIS al 1-800-MEDICARE (1-800-633-4227).